Photo courtesy of Latino Health Access
America Bracho, MD, MPH, is the President and CEO of Latino Health Access, a center for health promotion and disease prevention in Santa Ana, California. The work of Latino Health Access has been featured in an HBO documentary, a TEDMED talk, and by journalist Bill Moyers. Dr. Bracho will be a keynote presenter at the IHI Summit on Improving Patient Care (April 26–28, 2018 in San Diego, CA). In this interview, she talks about the power of asking hard questions and looking beyond the health care system for the answers to chronic health problems like diabetes and obesity.
Chronic illnesses like diabetes are a problem in many communities across the US. What have you learned from your work in Santa Ana that could be applied nationwide?
We have learned in our practice not to confuse people with their problems. People are not problems. People have problems, and when we see people with problems as part of the solution, we have more hands to find answers.
But first — to solve problems like chronic illnesses — we must ask why they are increasing. There are many reasons. People are living longer, of course. But it’s also because of the way we live, and where we live. Over and over life is demonstrating that where we work, play, learn, and live has everything to do with our health.
For example, many people have less time available to exercise, or to pay attention to their nutrition. How many places across the nation and across the world don’t have enough food that is appropriate or affordable? Think of how many people don’t live near places to play. People are becoming more sedentary. Obesity is increasing.
We’ve also learned lessons about how to approach solutions. What doesn’t work, for example, is applying “solutions” when we refuse to see the problems behind the problems.
For example, we want to address obesity without addressing inequity. We want to address nutrition without addressing food insecurity. We want to address the fact that we have more people living with chronic illnesses at home without addressing the family environment. We want to encourage people to exercise without addressing safety in neighborhoods.
Some people assume that addressing issues like unemployment, housing, food, and education makes things more complicated, but I’ve seen chronic illnesses become more manageable by addressing social determinants. And they become more manageable not just by addressing them, but by addressing them with the people affected by chronic conditions. It seems like we have two societies divided between problem solvers and people who are seen as the problem.
You’ve said that medical approaches alone won’t solve systemic issues. Would you share an example to illustrate what you mean?
Medical treatment obviously has its place in society. But the World Health Organization says that health is a stage of wellness that is physical, mental, and social. It also says that health is not the absence of infirmity. What I'm saying is that you are not going to have a healthy nation just by focusing on medication.
Asthma is a good example of this. In high prevalence areas, the most common reason why a child has an asthma crisis is due to housing — this includes the carpets, mold, roaches. Yes, it’s important that this kid has his asthma medication. Yes, it’s important that he has insurance, but his mom might not have been trained appropriately to provide his treatments, or she may have trouble reading. Mom might also have a job that she’ll lose if she keeps taking her child to the doctor or leaving work early to go to the pharmacy before it closes. In a situation like this, the solution is not just a medical thing.
How can doctors who may not spend much time in their patients’ communities avoid what you describe as “creating solutions from behind a desk”?
To avoid creating solutions from behind a desk, doctors need to start by assessing their reality. What helps my team is when we examine what we want to accomplish. We try to be honest in answering certain questions. Are we getting the results we want? Why not? Is the situation making sense to me?
Maybe you're seeing some good results, but you need to improve in certain areas. Maybe you find yourself sometimes overwhelmed as a provider. That means asking different questions. Who else needs to be involved?
For example, to get good results in the transition from hospital to home, you need to engage patients and families. Do you see patients and families as experts? Because it’s difficult to engage patients and families if you don’t respect what they have to contribute.
A good way to get “unstuck” is to ask, “If I want to use my leadership and my resources in a way that is cost-effective, how do I maximize my leadership? How do I engage more people as part of a team that can help me accomplish what needs to be accomplished?” By generating questions that allow candid conversations about what patients really need, people can move to a more productive, satisfying way of working.
The majority of physicians after a while find themselves a little bit stuck, seeing the same problems over and over. We have to ask hard questions about all of our options or our ability to problem solve will be limited.
You’ve said one of the most important things for your health is to participate. Could you describe how you've come to that conclusion?
We wrote a book about Latino Health Access, and we ask questions about this all over the world in our trainings: What happens when people participate? What happens when they don’t?
Participation is powerful on an individual level when you are more active with your physician, when you work together on a treatment plan. Participation is powerful when you are more active with the teacher of your kids, working on reading at home if they’re having trouble at school. When we vote, when we are engaged in the life of our communities, we make sure our voice is heard. We vote and become activists to help create the kinds of neighborhoods that support better health.
Universally, people see the power of participating and participating together. Participation is what transforms hope into things that are tangible.
Editor’s note: This interview has been edited for length and clarity.
Learn more from Dr. Bracho during her keynote presentation at the IHI Summit (April 26–28, 2018 in San Diego, CA).